<< >> NASA ASRS Report 203351, February 1992

Heavy transport frt aircraft departs with pilot passenger on board with an inoperative oxygen system in violation of FARS. Aircraft maintenance discrepancy discovered in postflt inspection.

Attributes
ACN	203351
Time
Date	199202
Day	Thu
Local Time Of Day	0001 To 0600
Place
Locale Reference	airport : sdf
State Reference	KY
Altitude	agl bound lower : 0 agl bound upper : 0
Environment
Flight Conditions	VMC
Light	Night
Aircraft 1
Controlling Facilities	tracon : syr
Operator	common carrier : air carrier
Make Model Name	Heavy Transport, Low Wing, 4 Turbojet Eng
Navigation In Use	Other
Flight Phase	ground : preflight ground : parked
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : atp
Experience	flight time total : 8000
ASRS Report	203351
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Events
Anomaly	aircraft equipment problem : critical non adherence : far non adherence : published procedure
Independent Detector	other flight crewa
Resolutory Action	none taken : detected after the fact
Consequence	Other
Supplementary
Primary Problem	Aircraft
Air Traffic Incident	Pilot Deviation other

Narrative:

Inadequate preflight by engineer. This was a cargo aircraft with 2 jumpseats in cockpit and 2 jumpseats located in entry vestibule. All jumpseats were occupied. Upon arrival at destination, the captain (only out of habit) tried to turn off the courier oxygen and bleed the system, only to find that the seats in the vestibule had an oxygen system that was deferred. We checked the log, and found no mention of the deferral. The aircraft had just returned to service after extensive maintenance (90 days plus), and apparently all references regarding the oxygen system being disconnected were inadvertently deleted from the log. While the jumpseaters were all pilots, and should have preflted their own oxygen system, the captain felt that responsibility fell to the flight engineer. Hopefully, everyone involved will be more aware.

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Original NASA ASRS Text

Title: HVT FRT ACFT DEPARTS WITH PLT PAX ON BOARD WITH AN INOP OXYGEN SYS IN VIOLATION OF FARS. ACFT MAINT DISCREPANCY DISCOVERED IN POSTFLT INSPECTION.

Narrative: INADEQUATE PREFLT BY ENGINEER. THIS WAS A CARGO ACFT WITH 2 JUMPSEATS IN COCKPIT AND 2 JUMPSEATS LOCATED IN ENTRY VESTIBULE. ALL JUMPSEATS WERE OCCUPIED. UPON ARR AT DEST, THE CAPT (ONLY OUT OF HABIT) TRIED TO TURN OFF THE COURIER OXYGEN AND BLEED THE SYS, ONLY TO FIND THAT THE SEATS IN THE VESTIBULE HAD AN OXYGEN SYS THAT WAS DEFERRED. WE CHKED THE LOG, AND FOUND NO MENTION OF THE DEFERRAL. THE ACFT HAD JUST RETURNED TO SVC AFTER EXTENSIVE MAINT (90 DAYS PLUS), AND APPARENTLY ALL REFS REGARDING THE OXYGEN SYS BEING DISCONNECTED WERE INADVERTENTLY DELETED FROM THE LOG. WHILE THE JUMPSEATERS WERE ALL PLTS, AND SHOULD HAVE PREFLTED THEIR OWN OXYGEN SYS, THE CAPT FELT THAT RESPONSIBILITY FELL TO THE FLT ENGINEER. HOPEFULLY, EVERYONE INVOLVED WILL BE MORE AWARE.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.